MEDICARE: MS. DAWN WILSON LOVE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225000000X	Orthotic Fitter

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M2549	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1114060845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DAWN WILSON LOVE

Provider Business Mailing Address
First Line	:	9280 COLLEGE PKWY STE 3
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33919-4848
Country	:	US
Telephone Number	:	239-985-7300
Fax Number	:

Provider Business Practice Location Address
First Line	:	9280 COLLEGE PKWY
Second Line	:	SUITE 3
City	:	FORT MYERS
State	:	FL
Zip	:	33919-4848
Country	:	US
Telephone Number	:	239-985-7300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	12/17/2007

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